What are the treatment options for an anxiety attack?

Treatment of Anxiety Attack

For an acute anxiety attack, initiate slow, deep breathing exercises immediately (6-10 breaths per minute) while simultaneously assessing whether this represents an isolated panic attack or part of an underlying anxiety disorder requiring ongoing pharmacological and psychological treatment. 1, 2

Immediate Management of Acute Anxiety Attack

Breathing Techniques (First-Line Acute Intervention)

• Implement slow, deep breathing at a rate of 6-10 breaths per minute for at least 5 minutes to rapidly reduce anxiety symptoms and restore vagal tone. 1, 2, 3
• Slow breathing significantly increases parasympathetic activity (measured by HF power on HRV) and reduces state anxiety within a single session, with effects particularly pronounced in older adults. 3
• Avoid fast-only breathing patterns, as these are ineffective and may worsen symptoms. 2
• Respiratory control techniques work by reversing hyperventilation-induced panic symptoms and should include reattribution training (explaining that symptoms result from overbreathing rather than catastrophic causes). 4

Acute Pharmacological Management (When Breathing Techniques Insufficient)

• Alprazolam 0.25-0.5 mg can be administered for immediate relief of severe anxiety attacks, though this should not be the primary long-term strategy. 5
• Alprazolam provides rapid anxiolytic effects but carries significant risks of dependence, particularly with doses above 4 mg/day and prolonged use. 5
• Benzodiazepines should be reserved for acute situations where breathing techniques are insufficient and while establishing longer-term treatment. 6

Ongoing Treatment for Anxiety Disorders

First-Line Pharmacological Treatment

• Initiate an SSRI (escitalopram 5-10 mg daily or sertraline 25-50 mg daily) as first-line pharmacological treatment, titrating slowly over 1-2 weeks to minimize initial activation symptoms. 7, 8
• Escitalopram and sertraline are preferred over other SSRIs due to superior efficacy, favorable side effect profiles, and lower discontinuation syndrome risk. 7, 8
• For fluoxetine specifically, start at 5-10 mg daily and increase by 5-10 mg every 1-2 weeks, targeting 20-40 mg daily by weeks 4-6, with maximal benefit expected by week 12. 9, 7
• Venlafaxine extended-release (75-225 mg/day) is an effective alternative SNRI, though it requires blood pressure monitoring due to hypertension risk. 7, 8

Critical Pitfall: Avoid paroxetine as a first-line agent due to higher discontinuation syndrome risk and potentially increased suicidal thinking compared to other SSRIs. 8

Response Timeline and Monitoring

• Assess treatment response at 2 weeks (statistically significant improvement), 6 weeks (clinically significant improvement), and 12 weeks (maximal benefit) using standardized anxiety scales. 6, 7
• If inadequate response after 8 weeks at therapeutic doses, switch to a different SSRI or SNRI rather than continuing ineffective treatment. 6, 7
• Monitor for common side effects including nausea, sexual dysfunction, headache, insomnia, and activation symptoms, which typically emerge within the first few weeks. 7, 8

Psychological Treatment (Essential Component)

• Initiate individual cognitive behavioral therapy (CBT) targeting anxiety-specific patterns, ideally in combination with pharmacotherapy for optimal outcomes. 6, 7, 8
• Individual CBT is superior to group therapy for anxiety disorders, with large effect sizes (Hedges g = 1.01 for GAD). 7
• CBT should include 12-20 structured sessions incorporating psychoeducation, cognitive restructuring, relaxation techniques, and exposure when appropriate. 7
• Combination treatment (SSRI + CBT) is superior to monotherapy alone for most patients. 8

Treatment Algorithm for Inadequate Response

1. Week 0-2: Start SSRI at low dose + breathing techniques + consider CBT referral 7, 8
2. Week 4: Assess response; if inadequate, increase SSRI dose 6, 7
3. Week 8: If still inadequate response despite therapeutic doses, switch to different SSRI/SNRI 6, 7
4. Week 12: If no improvement with second agent, consider adding CBT (if not already implemented) or switching to pregabalin/gabapentin as second-line agents 7

Special Populations and Considerations

• For patients with comorbid depression and anxiety, prioritize treatment of depressive symptoms first, or use a unified protocol combining CBT for both conditions. 6
• Duloxetine (60-120 mg/day) offers additional benefits for patients with comorbid pain conditions. 7
• Provide culturally informed and linguistically appropriate education about anxiety symptoms, treatment options, and warning signs of worsening. 6

Critical Pitfall: Avoid tricyclic antidepressants due to unfavorable risk-benefit profile, particularly cardiac toxicity. 7

Discontinuation Strategy

• Taper SSRIs gradually (decrease by no more than 25-50% every 1-2 weeks) to avoid discontinuation syndrome, particularly with shorter half-life agents like sertraline and paroxetine. 8, 5
• Discontinuation symptoms include dizziness, fatigue, headaches, nausea, insomnia, and rebound anxiety. 8
• Fluoxetine's longer half-life minimizes discontinuation risk and may be beneficial for patients with adherence concerns. 7, 9